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Inspection report

Date of Inspection: 20 May 2014
Date of Publication: 3 July 2014
Inspection Report published 03 July 2014 PDF | 81.43 KB

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 20 May 2014, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members, talked with staff and reviewed information given to us by the provider.

Our judgement

The provider had an effective system to regularly assess and monitor all aspects of the quality of service that people receive.

Reasons for our judgement

During our visit we met with the home’s owner / manager and the new deputy manager. The manager told us that she was planning to “Step down as the registered manager” and that “The deputy manager is responsible for the day to day running of the home. She will apply to be the manager within the next month”.

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. Since the appointment of the deputy manager there had been regular staff meetings. This was confirmed by the staff we spoke with. We saw that people were asked their opinion during the day where a choice was available. We were told that changes were made to peoples care in response to external professional advice. For example one person had a specialised bed following an assessment by a district nurse.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. We looked at accident and incident records and saw that there was a system in place to analyse the accidents and incidents. Measures had been put in place to reduce the risk of any recurrence.

There had been no complaints to the service from people living at the home or their families since our last inspection. The provider had a complaints procedure in place that was available to all people and their representatives. Staff we spoke with were aware of the actions they should take in the event of a complaint being raised with them.

The deputy manager had assessed and monitored the quality of service that people received against the requirements of the essential standards. This included auditing the routines within the home, care plans, staff training and recruitment. We saw evidence that the information from these audits was used to improve the quality of the service. For example there was a new style of care plan, which was individual and person centred. Staff had had their care delivery observed and had formal supervision scheduled. The provider had a system for ensuring training was up to date. We saw that there was a schedule of ongoing training. The deputy manager was reviewing the shift times to see if they could better accommodate people’s bedtime preferences. The deputy manager's assessment of the outcomes we assessed during this inspection matched our findings of compliance.